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Eating Disorders CONFIDENTIAL Second draft for consultation July 2003 Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders National Clinical Practice Guideline Number ___ National Collaborating Centre for Mental Health Commissioned by the National Institute for Clinical Excellence CONFIDENTIAL Second draft for consultation September 2003 Eating Disorders Guideline Development Group Members Professor Simon Gowers Professor of Adolescent Psychiatry University of Liverpool Guideline Development Chair Mr Stephen Pilling Co-Director, National Collaborating Centre for Mental Health, and Camden and Islington Mental Health and Social Care Trust. Professor Janet Treasure Professor of Psychiatry Eating Disorders Unit Guys Kings and St Thomas School of Medicine Kings College London South London and Maudsley NHS Trust Lead, Topic Group on Physical Management Professor Christopher Fairburn Wellcome Principal Research Fellow and Professor of Psychiatry Department of Psychiatry, Oxford University Lead, Topic Group on Psychological Interventions Dr Bob Palmer Senior Lecturer in Psychiatry University of Leicester Lead, Topic Group on Service-level Interventions Dr Lorraine Bell Consultant Clinical Psychologist Eating Disorders Team, Portsmouth Health Care NHS Trust Ms Nicky Bryant Chief Executive Eating Disorders Association (March 2002-2003) Dr Rachel Bryant-Waugh Consultant Clinical Psychologist, West Hampshire NHS Trust Honorary Senior Lecturer, University of Southampton Mr Peter Honig Family Therapist Phoenix Centre Eating Disorders Service Cambridgeshire and Peterborough Mental Health Partnership NHS Trust 2 CONFIDENTIAL Second draft for consultation September 2003 Dr Pippa Hugo Child and Adolescent Psychiatrist St. George's Eating Disorder Service, South West London and St. George's Mental Health NHS Trust. Dr Robert Mayer General Practitioner Highgate Group Practice, London Mr Ciaran Newell Consultant Nurse Eating Disorder Service, Dorset Healthcare NHS Trust Ms Jane Nodder Patient representative, London Dr Deborah Waller General Practitioner 19 Beaumont Street, Oxford Ms Susan Ringwood Chief Executive Eating Disorders Association (December 2002 – January 2004) Dr Ulrike Schmidt Senior Lecturer in Eating Disorders Eating Disorders Unit, Institute of Psychiatry NCCMH Staff Dr Catherine Pettinari: Senior Project Manager Dr Craig Whittington: Senior Systematic Reviewer Dr Judit Simon: Health Economist Ms Heather Wilder: Information Scientist Ms Ellen Boddington: Research Assistant Mr Lawrence Howells: Research Assistant 3 CONFIDENTIAL Second draft for consultation September 2003 1 Introduction 7 1.1 National guidelines 8 1.2 The national eating disorders guideline 11 2 Eating disorders 14 2.1 Anorexia nervosa 14 2.2 Bulimia nervosa 19 2.3 Atypical eating disorders (eating disorders not otherwise specified; EDNOS) including binge eating disorder 23 2.4 Incidence and prevalence of eating disorders 25 2.5 The aetiology of eating disorders 27 2.6 Use of health service resources 30 2.7 The treatment and management of eating disorders in the NHS 34 2.8 Assessment 39 2.9 Engagement, consent and the therapeutic alliance 41 2.10 The patient experience of eating disorders 42 2.11 The involvement of family members / carers 46 2.12 Stigma 50 3 Methods used to develop this guideline 52 3.1 Overview 52 3.2 The Guideline Development Group 52 3.3 Clinical questions 54 3.4 Systematic clinical literature review strategies 54 3.5 Health economics review strategies 66 3.6 Stakeholder contributions 66 3.7 Validation of this guideline 67 4 Summary of recommendations 68 4.1 Introduction 69 4.2 Care across all conditions 69 4.3 Identification and management of eating disorders in primary care and non-mental health settings 70 4.4 Anorexia nervosa 71 4.5 Bulimia nervosa 77 4 CONFIDENTIAL Second draft for consultation September 2003 4.6 Treatment and management of atypical eating disorders including binge eating disorder 80 4.7 Research recommendations 81 5 Identification of eating disorders in primary care 83 5.1 Introduction 83 5.2 Screening 84 6 Treatment and management of anorexia nervosa 91 6.1 Introduction 91 6.2 Psychological interventions 91 6.3 Pharmacological interventions 104 6.4 Management of physical aspects 107 6.5 Service interventions 120 6.6 Predicting the outcome of treatment and recovery from anorexia nervosa 131 7 Treatment and management of bulimia nervosa 133 7.1 Introduction 133 7.2 Psychological interventions 133 7.3 Pharmacological interventions 144 7.4 Antidepressant drugs compared to psychological interventions and their combination 150 7.5 Management of the physical aspects of bulimia nervosa 159 7.6 Service level interventions 168 7.7 Predicting the outcome of treatment and recovery from bulimia nervosa 170 8 Treatment and management of atypical eating disorders (eating disorders not otherwise specified) including binge eating disorder 173 8.1 Introduction 173 8.2 Psychological interventions 173 8.3 Pharmacological interventions 181 8.4 Management of physical aspects 183 8.5 Service level interventions 183 9 Health economics evidence 184 9.1 Systematic literature review 184 9.2 Cost-effectiveness modelling 188 5 CONFIDENTIAL Second draft for consultation September 2003 10 Criteria for auditing the management of eating disorders 200 10.1 Objectives for the audit 200 10.2 Individuals to be included in an audit 200 10.3 Measures that could be used as a basis for an audit 200 11 References 209 12 Glossary 238 6 CONFIDENTIAL Second draft for consultation September 2003 1 Introduction This guideline has been developed to advise on the identification, treatment and management of the eating disorders anorexia nervosa, bulimia nervosa and related conditions. The guideline recommendations have been developed by a multidisciplinary group of healthcare professionals, patients and their representatives, and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high quality care for those with eating disorders while also emphasising the importance of the experience of care for patients and carers. Eating disorders comprise a range of syndromes encompassing physical, psychological and social features. Whilst the acute physical complications of these disorders may provoke great concern in family members and health service staff, anorexia nervosa and bulimia nervosa are frequently chronic conditions with substantial long-term physical and social sequelae, from which recovery is difficult. Long-term disabilities include negative effects on employment, fertility, relationships and parenting. The impact of a person’s eating disorder on home and family life is often considerable and family members may carry a heavy burden over a long period of time. Family members are often at a loss to know how to help and offer support to an affected relative. About 1 in 250 females and 1 in 2000 males will experience anorexia nervosa, generally in adolescence or young adulthood. About five times that number will suffer from bulimia nervosa. Other atypical eating disorders are more common still, though many will not receive treatment. As eating disorders commonly develop during adolescence, they can blight physical and social development and many sufferers fail to reach their academic potential. Depressed mood is a common feature, partly because of these adverse consequences and also because of the distressing nature of the central symptoms of these disorders. The adverse physical consequences of dieting, weight loss and purging behaviours are notable and sometimes prove fatal. Indeed, anorexia nervosa has the highest mortality rate of any psychiatric disorder of adolescence. The treatment experience of those with eating disorders is extremely variable. In part, this relates to the inherent ambivalence to treatment commonly experienced by those with these conditions. It is also due to the uneven provision of effective psychiatric treatments that range from high quality age- appropriate specialist services, to basic generic provision in areas of the country where skills and experience are scarce. Sadly, a number of those with eating disorders will receive negative attitudes from inexperienced clinical 7 CONFIDENTIAL Second draft for consultation September 2003 staff and they may on occasion fear being trapped in treatment rather than helped by it. This guideline addresses aspects of service provision, physical management and therapeutic approaches for those with eating disorders from the age of 8 upwards. Although the evidence base is rapidly expanding, there are a number of major gaps and future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address these gaps in the evidence base. In the meantime, we hope that the guideline will assist clinicians, patients and carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists. 1.1 National guidelines 1.1.1 What are clinical practice guidelines? Clinical practice guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods
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